"Social Determinants of Health Screening Tools"
Social determinants of health screening is the practice of asking patients a standardized set of questions about non-medical conditions that affect health, such as food, housing, transportation, utilities, and personal safety, and recording the answers in the medical record so they can be acted on. The screen itself is a short questionnaire. What distinguishes one instrument from another is which domains it covers, how long it takes, who developed it, and whether it is designed for population reporting or for individual referral. This page is a reference to the named, publicly available instruments that health centers, hospitals, and health plans actually use, along with the coding and reporting rules that surround them.
This page is general information about screening instruments, coding, and reporting rules. It is not medical, legal, coding, or compliance advice, and it does not describe what any individual patient needs. Screening requirements and code sets change on annual cycles, so confirm anything binding with the issuing body, CMS materials for your program year, and your own compliance team.
What SDOH Screening Is, and What It Is Not
A screening instrument identifies self-reported social needs. It does not diagnose anything. Terminology has also shifted: federal programs increasingly use "health-related social needs" or "social drivers of health" for the individual-level needs a clinic can act on, reserving "social determinants of health" for the broader structural conditions that produce them. The instruments below screen for needs.
Three design questions separate the tools. First, breadth: a two-item food insecurity screen and a twenty-item multi-domain assessment serve different purposes. Second, setting: some were built for federally qualified health centers, others for hospital workflows or pediatric primary care. Third, downstream use: an instrument built for quality reporting has to produce a clean screen-positive rate, while one built for care planning has to produce enough detail to make a referral.
Reference Table: Named SDOH Screening Instruments
| Instrument | Developer | Domains covered | Length | Typical setting |
|---|---|---|---|---|
| PRAPARE | National Association of Community Health Centers, with the Association of Asian Pacific Community Health Organizations, the Oregon Primary Care Association, and the Institute for Alternative Futures | Personal characteristics, family and home, money and resources, social and emotional health, plus optional questions on incarceration, safety, and domestic violence | 21 core measures plus 8 optional questions | Federally qualified health centers and community health centers |
| Accountable Health Communities Health-Related Social Needs (AHC HRSN) screening tool | CMS Innovation Center, developed for the Accountable Health Communities Model | Core: housing instability, food insecurity, transportation needs, utility difficulties, interpersonal safety. Supplemental questions cover additional domains | Ten core questions plus supplemental items | Hospitals, clinics, and community bridge organizations; its five core domains shaped the federal shortlist and remain the common reference set |
| Social Needs Screening Tool | American Academy of Family Physicians, through the EveryONE Project | Housing, food, transportation, utilities, childcare, employment, education, finances, personal safety | Published in a short form and a longer form | Family medicine and primary care practices |
| Hunger Vital Sign | Children's HealthWatch, derived from the USDA Household Food Security Survey Module | Food insecurity only | Two items | Any setting needing a rapid food insecurity screen, including pediatrics and emergency departments |
| WE CARE | Academic pediatric primary care research group led by Arvin Garg | Family social needs including food, housing, utilities, employment, education, and childcare | Brief parent-completed questionnaire | Pediatric primary care, paired with a referral step |
| Social Drivers of Health measures (SDOH-1 and SDOH-2) | Centers for Medicare and Medicaid Services, adopted through hospital quality reporting rulemaking | Food insecurity, housing instability, transportation needs, utility difficulties, interpersonal safety | Measure specification, not a questionnaire; hospitals chose a conforming instrument | Formerly Hospital Inpatient Quality Reporting; removed in the FY2026 IPPS final rule |
Other instruments exist, including proprietary tools embedded in electronic health records and health plan assessments. The list above is limited to publicly available, named instruments with an identifiable developer.
PRAPARE
PRAPARE stands for the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences. It was developed by the National Association of Community Health Centers together with partner organizations, and it is the instrument most closely associated with the community health center field. Its design goal was a standardized national data set that health centers could collect, code, and aggregate, supporting both individual care and center-level population reporting.
PRAPARE is longer than the other tools on this list because it is doing more work. It captures demographic and personal characteristics alongside need domains, which makes it useful for stratifying outcomes by population, and it includes a small set of sensitive optional questions that many sites administer separately or omit. It has been mapped to standard coding vocabularies and implemented as templates in several electronic health record systems, which is a practical reason for its adoption. Health centers running PRAPARE at scale usually pair it with an outreach workflow, since a substantial share of screens happen outside the exam room. Our overview of text messaging for community health centers covers how that outreach is typically structured.
The AHC HRSN Screening Tool
The Accountable Health Communities Health-Related Social Needs screening tool was developed by the CMS Innovation Center for the Accountable Health Communities Model, which tested whether systematically screening Medicare and Medicaid beneficiaries for social needs and connecting them to community services affected utilization. The tool has ten core questions covering five core domains: housing instability, food insecurity, transportation needs, utility difficulties, and interpersonal safety. A set of supplemental questions covers further domains for sites that want them.
The AHC tool matters beyond the model that produced it, because its five core domains became the de facto federal shortlist. When federal quality measures and state Medicaid programs specify social needs screening, they generally track those same five domains, and hospitals frequently adopt the AHC core items directly to satisfy them.
Short-Form Screeners
The Hunger Vital Sign is a two-item food insecurity screener validated by Children's HealthWatch and derived from the longer USDA Household Food Security Survey Module. It asks whether, in the past twelve months, the household worried food would run out before there was money to buy more, and whether food bought did not last. An affirmative or "sometimes true" response to either item is a positive screen. Its value is speed: it fits into intake, triage, and text-based outreach.
The American Academy of Family Physicians Social Needs Screening Tool, published through the EveryONE Project, covers a broader set of domains in a form designed for family medicine workflow, and is distributed in both a short and a longer version so practices can match instrument length to visit time. WE CARE, developed by an academic pediatric primary care research group led by Arvin Garg, pairs a brief parent-completed questionnaire with a structured referral step, which is the design feature that distinguishes it: the instrument and the response are treated as one intervention rather than two.
Coding and Reporting: Z Codes and the CMS Measures
Screening produces data only if it is coded. ICD-10-CM includes a block of codes, Z55 through Z65, titled "Persons with potential health hazards related to socioeconomic and psychosocial circumstances." These cover education and literacy (Z55), employment and unemployment (Z56), occupational exposure (Z57), the physical environment (Z58), housing and economic circumstances (Z59), the social environment (Z60), negative life events in childhood (Z61), upbringing (Z62), the primary support group and family circumstances (Z63), and other psychosocial circumstances (Z64 and Z65).
Z59 is the most heavily used subcategory, since it holds homelessness, inadequate housing, and food insecurity concepts. The specific codes within these ranges are revised in the annual ICD-10-CM update cycle, and subcodes have been added in recent years to distinguish, for example, sheltered from unsheltered homelessness. Confirm the current code set for the fiscal year you are coding in. Coding conventions also allow social needs information documented by non-physician members of the care team to support Z code assignment, which is why intake and navigation documentation matters.
On the reporting side, CMS previously adopted two social drivers of health measures into hospital quality reporting through inpatient prospective payment system rulemaking. The first, commonly referred to as SDOH-1, reported the percentage of admitted patients screened for the five core domains. The second, SDOH-2, reported the screen-positive rate for each domain. Both were phased in through a voluntary reporting period and then became required, and both have since been removed. In the FY2026 Hospital Inpatient Prospective Payment System final rule, issued July 31, 2025, CMS removed SDOH-1, SDOH-2, and the Hospital Commitment to Health Equity measure from the Hospital Inpatient Quality Reporting program beginning with the CY2024 reporting period. CMS made a parallel removal on the outpatient side. That does not mean screening stopped: many state Medicaid programs, accreditation bodies, and value-based contracts still require it, and hospitals that built screening workflows are largely continuing them. It does mean any guidance describing SDOH-1 and SDOH-2 as a live federal reporting requirement is out of date. Confirm what applies to you for the current program year with CMS materials and your own compliance team.
Closing the Loop After the Screen
A screen with no response path is a documentation exercise. Closed-loop referral means the referral is transmitted to a community organization, the organization records what happened, and the outcome returns to the clinical record. The main obstacles are structural: community organizations often lack shared systems, consent is required to share need data, and follow-up depends on reaching someone by phone.
Two things help. On the data side, the Gravity Project has developed HL7 standards and value sets for social determinants data, so screening responses, goals, interventions, and outcomes can be exchanged in a common structure rather than as free text, and SDOH data elements have been incorporated into the United States Core Data for Interoperability. On the human side, follow-up almost always falls to navigation or community health worker staff, whose role is described in our explainer on patient navigation.
Frequently Asked Questions
What is the most widely used SDOH screening tool?
There is no single national standard. PRAPARE is the most common instrument in community health centers, while hospitals frequently use the AHC HRSN core items because they map directly to federal quality measure domains. Short screeners like the Hunger Vital Sign are widely embedded inside other tools rather than used alone.
What does PRAPARE stand for?
Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences. It was developed by the National Association of Community Health Centers with the Association of Asian Pacific Community Health Organizations, the Oregon Primary Care Association, and the Institute for Alternative Futures, primarily for use in community health centers.
How many questions are on the AHC HRSN screening tool?
The core tool has ten questions covering five domains: housing instability, food insecurity, transportation needs, utility difficulties, and interpersonal safety. A separate set of supplemental questions covers additional domains such as financial strain, employment, education, and social supports for organizations that want broader coverage.
Are hospitals required to screen for social determinants of health?
Not by CMS, as of the FY2026 rulemaking. CMS had adopted social drivers of health screening and screen-positive-rate measures, SDOH-1 and SDOH-2, into hospital inpatient quality reporting, then removed them in the FY2026 Hospital Inpatient Prospective Payment System final rule issued July 31, 2025, beginning with the CY2024 reporting period. Screening obligations may still reach a hospital through state Medicaid rules, accreditation standards, or payer contracts. Verify what applies for your program year with CMS materials and your compliance team.
What are ICD-10 Z codes for social determinants of health?
They are the Z55 through Z65 code block, covering socioeconomic and psychosocial circumstances such as education and literacy problems, employment issues, housing and economic circumstances, and family and social environment. Z59 covers housing and food-related concepts and is the most frequently used subcategory. Codes are updated annually.
Can non-clinicians document social needs for coding purposes?
Coding guidance allows social determinants information documented by other members of the care team, not only the billing clinician, to support Z code assignment, provided it is part of the official record. This is why intake staff, social workers, and navigators are central to whether screening data ever becomes coded data.
Is the Hunger Vital Sign a validated instrument?
Yes. It is a two-item screener validated by Children's HealthWatch and derived from the USDA Household Food Security Survey Module. Its brevity makes it suitable for intake forms, triage, and text-based outreach, and it is often embedded as the food domain inside longer screening instruments.
What does closed-loop referral mean in SDOH screening?
It means the referral to a community organization is transmitted, acted on, and the result returned to the health record, rather than ending when the referral is made. It requires consent, a data path between clinical and community systems, and a reliable way to reach the patient for follow-up.
Reaching people after the screen
Screening is the easy half. The harder half is following up with people who do not answer phone calls, confirming a referral connected, and re-screening on schedule. FRANSiS supports that follow-up with two-way texting and an AI Powered Helper that drafts replies for your staff to review and send, with HIPAA compliance supported and a signed BAA included. See FRANSiS for healthcare or contact us to talk through your screening and referral workflow.
